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SAN JOAQUIN LOCAL :HEALTH DISTRICT - <br /> FOFiiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7G-,5�T <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Satz Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the <br /> jj San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONISa2J�aZ ,� [�(/,C. d� CENSUS TRACT <br /> Owner r s Name ,, )V Phone a- 7,->r,3 <br /> Address City C p4 oz] <br /> Contractor's Name 1 AJ LicenseO) Phone 3$�2ao 7 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION- /7 DESTRUCTION /^7 <br /> PUMP INSTALLATION /. / PUMP REPAIR PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (n <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private - . Drilled Dia. of Well. Casing � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATIONN: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR:- 1,Y State Work Done ADDs <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. ' Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting..the- well in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TING MFjpAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR MENTzVSE ONLY <br /> PHASE I <br /> APPLICATION ACCEP tg44 NDTI DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAF INSPECTI N <br /> INSPECTION BY DATE INSPECTION- BY ATE <br /> '; E H 1426 Rev. 1-74 1-74 2M <br />